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Treatment recommendations for hsts transkids

by S. Alejandra Velasquez

Our first recommendation is for the medical differentiation of homosexual transsexuality and autogynephilic transsexuality as two completely unrelated conditions. The two conditions should not be lumped together as different forms of the same phenomenon but should have separate diagnostic sections in the DSM IV.

One of the biggest problems facing transkids is the lack of meaningful counseling as children and treatment protocols as teenagers specifically helpful for our population. This is in part because we have no meaningful social category within which we may be therapeutically understood. Our criticism of the current gender identity model of transsexuality is not a theoretical objection, it is because this model is taylored exclusively to the social and therapeutic needs of AGP transsexuals and is irrelevant to homosexual transsexuals. Our problem is not with autogynephilia but to the social impact of an autogynephilia centered psychological model upon our lives. Meaningful medical help for our type of transsexual can only be provided with an adequate understanding of the etiologies, problems and desired goals specific to hsts.

In almost all ways, hsts and agp transexuality are completely different conditions which happen to intersect with the one shared experience of genital surgery. Our lives both before and after that shared experience are extremely divergent. It is only logical that the two different psychological conditions which have no shared symptomology, would have very different diagnoses and modalities of treatment which reflect those differences.

We also recommend counseling be available for children who are possible transkids, especially as they approach puberty. We are not advising that children be treated for childhood gender identity disorder, a diagnosis we dispute. We are recommending counseling when it seems appropriate for the difficulty of being different and misunderstood as children.

Counselors or therapists need to be knowlegable about homosexual transsexuality, though we realize that cannot happen overnight. It should not be assumed that someone who is proficient and knowlegable in evaluating and treating agp transsexuals is also qualified to counsel or treat hsts transkids.

Feminine boys are stigmatized in almost all societies, but trying to prevent stigmatization by traumatizing potentially gay and hsts children into more acceptable sex typed behavior for their birth sex only creates more shame in adults. It is hard being a transkid but we know that with understanding and sensible treatment choices, the outcome can be very good. It should be understood that publicly out adult agp transsexuals are not representative of adult hsts. It's better to be a well adjusted adult with a different childhood than an unhappy adult with a more normal appearing childhood. Gender variant children should have meaningful psychotherapeutic support for coping with social stigmatization and for making logical decisions about their lives and bodies as they approach puberty.

A new set of relevant guidlines for counseling and treatment of hsts teenagers should be developed which will provide access to helpfull and appropriate medical procedures.

The Harry Benjamin (Now WPATH - editor) Standards of Care are inappropriate and unhelpful for hsts in most ways. There have been improvements to the HBSoC which potentially benefit hsts adolesecents but because the current understanding of transsexuality excludes homosexual transkids those changes are really focussed on a therapeutic model specific to agp teenagers.

It seems paradoxical but in many ways being a feminine transkid in western society can make the process of getting access to medical help more difficult, not easier. Parents do not want to accept that they have a child who is very different and the single most important factor in a transkids life is parental support and understanding. Adolescence is the time when transkids unequivably differentiate from non-transsexual children because it is increasingly impractical for us to live socially as boys as we get older and because there is no natural and practical developmental pathway for our sexuality as feminine boys who are sexually attracted to males. Our medical options should enable our ability to mature socially and sexually as teenagers. All of the following recommendations are based on the ability of transkids to determine what will benefit them personally, socially and sexually as they mature. We do not advocate at all the imposition of unwanted medicalization, only the logical self-actualized access to helpful medical technology which we know to be important and helpful to our population.

Some Specific Recommendations

Medical intervention to avoid masculinizing puberty.

This is the most important medical factor in our lives and will determine what choices we have and our chances for happiness later in life. Though transkids tend to be unusually feminine in appearance, masculinizing puberty can adversly affect our ability to present normally. Most hsts kids express their dissatisfaction with their sex identity to parents as young children and certainly around puberty, commonly between age 12 and 16 but also both younger and older. Unlike AGP transsexuals, it is usually no surprise to the families of hsts because our behavior and socialization has been obviously different from a young age. Transkids are very motivationally homogenous and uncomplex in their transsexuality, so it's logical that the decision to initiate hormonal intervention comes with an hsts pre-teens or teenagers request for help. Ideally we recommend a combination of estrogen to initiate feminizing puberty and anti-androgens to prevent any masculinization prior to surgery.

Change of social role, transition, during adolescence.

Because hsts transkids fit in socially and behaviorally better as girls our social lives as teenagers will simply benefit from living as the most appropriate sex to reduce social stigma and all the resulting frustration and psychological difficulty it causes us. In our experience transkids who have had medical and parental help in avoiding male puberty and living in their logical sex role early seem to do far better and have less problems than other hsts teenagers.

If it is not possible to begin feminizing puberty at the appropriate age then puberty delaying anti-androgens are the next best alternative. Preventing masculinizing puberty is of primary importance.

The fixed age requirements for begining hormonal intervention and surgery should be eliminated in favor of providing rational help to hsts transkids as it is requested. The requirement of the RLE (real life experience) should be eliminated for hsts transkids in favor of humanistic and common sense help.

Some of us might benefit best by transitioning at age 10 or 12, some at 16 or 18, depending on our social and familial situations. We do not view transition as a "test" or "real life experiences" but rather as positive changes in our lives. By the time we are young teenagers it is very obvious that the "real life experience" of living as boys has not been workable for us. There is no reason to require transkids to wait until they are 16 to begin hormone therapy or transition or to wait until they are 18 for permission to have SRS. For those of us denied services we often simply acquire hormones illegally and "transition" socially with no parental or professional support.

Surgery should be available after the adjustment is made to hormones and transition, when we feel ready for that step. It is extremely difficult to live for years prior to surgery for hsts transkids who do cannot pass as boys and who have transitioned. Ideally there should be a minimum of time spent "in-between" sexes because it is very psychologically damaging and potentially dangerous. Once an hsts transkid has transitioned and is doing well on hormones and states she is happy and ready to go forward then surgery should be available.

It's cruel to ask an adolescent at their sexual prime to be assexual for a year or two years. The so called "real life test" may be useful for autogynephilic transsexuals to see if they can make the huge adjustment to living in a nominally female role and if they can sustain the criticism from their family, co-workers, and take the harrasement from insensitive people. Hsts transkids on the other hand are not making a very large adjustment, receive less harrasement and criticism in a female role then in their prior nominally male role. While there is a fear that autogynephilic transsexuals, who most often have used their genitals for sexual relations as males, maybe have 'post-op regret' at the loss of that function, hsts transkids do not. It is frustrating for transkids to live as female, likely getting lots of attention from men for the first time in their lives, but not being able to date (these are adolescents). While the Harry Benjamin Standards of Care recommend a one year RLE for adult transsexuals, transkids who transition as teens in order to be happier and emotionally adjusted often find themselves in the situation of having to wait 2 or 4 or more years for surgery. This is unfair, harmful and dangerous.

Counseling for teenage transkids and their parents should be with specific understanding of the needs of hsts transkids which are generally different from the needs of AGP transsexuals and most definitely from those of older AGP transsexuals.

It is a paradox of the current understanding of transsexuality that hsts transkids who have spent their childhoods coping with the difficulty of being unacceptably feminine should be misunderstood and marginalized in obtaining medical help as m2f transsexuals but that is the situation most of us find ourselves in as teenagers. Typically "gender therapists" are familiar with the standard transsexual narrative which explains that transsexuals have a powerful urge to change their sex no matter what the cost in order to be congruent with some internal sense of their "gender identity", which may or may not have any relationship to their social identity. It does not occur to hsts transkids to explain themselves this way because that understanding is specific to agp transsexuals; transkids are motivated by the need to change their sex to match their external and socially connected genders and to have a chance to express their natural sexuality without risking being emotionally or physically harmed. We often find the less someone knows about 'transsexuals' the more able they are to help us, because what we really need is only a common sense understanding and not a whole philosophy on what 'transsexuality' ought to be about. Practical counseling for transkid teenagers should be focussed on providing meaningful help and not on theoretical abstractions about internal gender identity.

For example:
Our sexuality is important to us. Simply, social and sexual frustration is a major problem for transkids. This should not be a startling insight at all since adolescence is when we all learn about our sexuality - hsts transkids are no different. It is a common myth of the transsexual narrative that transsexuality does not involve sexuality but this is not true of hsts. Do not be surprised if hsts transkids are very interested in sex and sexuality.

Transkids like boys. They would like boys even if they stayed male. Being physically attractive is important to transkids because they want to attract boys, not to 'confirm their female identity', but simply because they like boys. Having good relationships is important in living a decent life, and the fact that this is significant to them does not mean that they're conflicted about their gender issues, it just means that they have the same concerns that normal people do.

Teen hsts should not be required to attend support groups for older transsexuals. The two groups have nothing in common and many of us have had upsetting experiences being forced to attend meetings with people who have had a transvestic etiology as opposed to a homosexual one.

Hsts transkids should not be subjected to embarrassing medical attention or incredulity over our birth sex when we talk to healthcare professionals. It is common for us to be asked to drop our pants by psychiatric personel for instance or to be told we may be intersexed rather than hsts. Endocrinologists frequently take it upon themselves to practice unasked for psychiatry with us. These attitudes are harmful and upsetting to teenagers who very often already have more than enough problems with embarrassment at home and school. We deserve to be treated with respect just like other teenagers.

When an hsts transkid goes on hormones, don't expect them to feel 'more complete' or 'more at peace' with themselves as a diagnostic feature of being a transsexual. Dressing up at home or doing little things to affect a more 'feminine' appearance while presenting as a gay boy, offers no relief to transkids because their gender issues are social and not personal. Suggesting they do so will only confuse them.

Transkids who have not transitioned socially are unlikely to put a great deal of importance on what pronoun you use for them or what name they're called. This is not a sign of having ambivalence to their gender or feeling conflicted about which gender they want to be; given that their gender is already at issue they may simply not care how a health care provider addresses them. Showing 'sensitivity' by trying to respect their 'gender identity', or worse insisting that they declare their 'gender identity', will only make them feel embarrassed. Hsts transkids are practical about identity issues so don't make a bigger deal about it than they do.

Transkids do not have feminine alter egos, they don't have 'guy mode' or 'girl mode', nor do they dress 'en femme.' Typically their voice is natural and untrained not a deliberate 'girl voice.' Assuming the way a transkid presents is just one of several "modes" they have is very likely incorrect; since they never develop a gender normative male presentation there is no dichotomy between 'guy mode' and 'girl mode' for them. Transkids only have one personality regardless of how they're dressed or what name they introduce themselves by.

Cosmetic surgery for transkids should be regarded the same was as cosmetic surgery in straight women. If they want cosmetic surgery, they want it to make them more attractive, so that they feel more confident in their apperance and so they're more desirable to men. Its not a surgery to 'confirm' their gender.

Transkids are likely to regard SRS in terms of funcitonality: they will want the surgery so they can have normal sex with straight men. There is nothing wrong with wanting it for inherently sexual reasons, and it should not surprise anyone that surgery on genitals is for sexual reasons. This should not be seen as a reason not to endorse their operation or operate on them. No one should have to suffer from a sexual dysfunction.

A Better Paradigm for Understanding and Better Treatment

Hsts transkids are caught between two harmfull and irrelevant social constructs: as children our gender variance, childhood gender identity disorder, is socially and parentally unacceptable. We are often problem children because we are unable to modify our behavior and achieve a believable gender presentation as boys. The current model of transsexuality is focussed on benefitting autogynephilic transsexuals, "men" who wish to "become women" and does not address the needs of transkids who need to get through adolescence with good medical help for maturing into the appropriate sex with minimum harm. A better way to think about hsts transkids is to understand how different children can grow up and mature into a more appropriate and workable sex, gender and sexuality, not "transitioning" into the "opposite sex" since our gender as boys is never adequately socially realized. We are one of the groups of children whose sex and gender differentiation isn't complete until the social part of our development plays out sufficiently into adolescence, when we are able to make the best logical choices for ourselves about our own lives.
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